According to a new report in the September issue of Spine Journal, hundreds of troops evacuated from Iraq and Afghanistan are suffering spinal pain that could be related to the psychological stress of war. (Airman 1st Class Natasha E. Stannard / Air Force)
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They can happen in an instant — devastating spinal injuries caused by an improvised explosive device, a bullet or the impact of a high-velocity artillery round.
Or they can come on slowly — crippling back conditions related to the daily strain of war, including carrying a 60-pound pack or wearing body armor.
But in many cases, according to a new report in the September issue of Spine Journal, hundreds of troops evacuated from Iraq and Afghanistan are suffering spinal pain that could be related to the psychological stress of war.
From 2000 to 2009, 598 troops suffered spinal cord injuries in combat, either a blunt trauma or a penetrating wound.
But from 2004 to 2007, nearly 2,500 personnel were evacuated from theater for back pain alone.
According to Dr. Eugene Carragee, a former Army reservist and orthopedic surgeon at Stanford University, those evacuations accounted for half of all combat-wounded evacuations.
"The numbers are startling. We went over the data a bunch of times and thought, ‘Wow, that's a lot of backaches,'" he said.
Because these injuries present an attrition problem for the services and a future health care burden for civilian doctors and the Veterans Affairs Department, they need further exploration, said Carragee, Spine Journal editor.
The causes for the backaches include the physical exertion of combat.
But if wartime wear and tear were the sole reasons troops were removed from the front lines for back pain, evacuations for the condition should have increased during periods of heavy fighting and sizable troop deployments, Carragee said.
Instead, studies show complaints of back pain actually decreased during these times.
In 2004 and 2005 — years of lower casualties — evacuations from theater for spinal pain and psychiatric conditions increased. Conversely, during the 2007 surge in Iraq, they dropped by one-third, according to a study by Dr. Steven Cohen with Johns Hopkins University.
"Anyone who says back pain is an excuse to leave — that these guys are just a bunch of wimps — is not understanding the data," Carragee said.
One of the biggest predictors of treatment for back pain among civilians is psychological resilience, Carragee said. The same proved true among service members.
In one VA study, nearly 80 percent of veterans being treated for spine pain tested positive for psychological stress, with 44 percent reporting severe stress.
"The neurophysiological stuff going on with [post-traumatic stress disorder] seems to be manifesting in back pain," Carragee said.
The relationship should serve as a wake-up call for physicians to consider the overall health and psychological fitness of their military patients, he added.
"I don't think anyone's reported on this before with veterans," Carragee said. "Those who have psychological issues have less reserve to deal with chronic pain, and the flip side is those with chronic pain [lose] their psychological reserves."
The Spine Journal editorial board devoted an entire issue to military back pain because so few civilian physicians understand military patients, he said.
According to the journal, after World War II, trade publications focused on battlefield and medical advancements and treatments because many of their patients were veterans.
Given the small percentage of the U.S. population who served in Iraq and Afghanistan, Spine Journal editorial board members were concerned that the lessons learned from these wars would be lost or misunderstood by civilian doctors.
"The guys who are being released from service are going to be extraordinarily hard to treat," Carragee said. "We wanted to shed some light on their problems."